After reviewing, consider the following questions. The rationale for these questions will be posted within this thread on July 23, 2015.

1. The provider billed a 99213 in addition to the chemotherapy services. Was this level of service supported?
2. In order to bill the E/M (if appropriate) with the chemotherapy services, modifier 25 would be needed. Is modifier 25 supported in this encounter based on the documentation?
3. Verify whether practice billed the chemotherapy services correctly:
-96413
- 96360
-96375
-96375
- J9265 x 3 units
- J2550 x 2 units
-J1200

Rationale:
1. The provider billed a 99213 in addition to the chemotherapy services. Was this level of service supported?99213 was supported by the documentation and medical necessity, but it was noted that a higher level of service could be supported based on the documentation and medical necessity as well. A 99214 was supported

2.In order to bill the E&M (if appropriate) with the chemotherapy services, a -25 modifier would be needed. Is a -25 modifier supported in this encounter based on the documentation?The -25 modifier was supported. The documentation indicates that the patient presented for evaluation to the provider of not only her current problem (breast cancer) but also for depression and nausea/vomiting. Each of these additional problems are appropriately addressed within the history and the plan of care.

3. Verify if the practice billed the chemotherapy services correctly:
96413 This is the proper initial code that should be reported
96360 This is an initial code and would not be supported. The appropriate code would be 96361
96375 This is the proper push code
96375 This is the proper push code
J9265 x 3 units This code in 2014 was a different code and was reported per 10mg. in 2015 this codes is now billed per 1mg and therefore should be billed for 30 units.
J2550 x 2 units Correct as billed
J1200 Correct as billed.

What if the patient had no other problems other than cancer? Would an E/M visit be supported prior to chemotherapy in that case? I see the scenario a lot in one of the clinics I audit for. Patient is scheduled for their routine chemotherapy and the provider is seeing the patient before the infusion every visit, patient is having no problems or side effects and the provider is billing an E/M on the same day. Thank you!